Individual at Wymott

Investigation into the circumstances surrounding the death of
a man at HMP Wymott in February 2005
Prisons and Probation Ombudsman for England and Wales
October 2005
The man who is the subject of this report died from natural causes in February
2005 at HMP Wymott. This is a report into the circumstances surrounding his
death. The loss of any family member is distressing, but especially so whilst
they are in custody. I offer my sincere condolences to the man’s family and
friends.
The investigation was carried out by two of my investigators. I would like to
thank the Governor of Wymott for making the necessary facilities available to
them.
In the course of the investigation, I asked the Chorley Primary Care Trust to
undertake a clinical review of the care and treatment received by the man
from Wymott. I am most grateful to them for their assistance.
The clinical review raises concerns about the medical care the man received
whilst in prison custody. My report makes recommendations for the prison in
partnership with the Primary Care Trust.
This report has been anonymised for publication on the Prison and Probation
Ombudsman website.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2005
2
Contents
Summary 4
HMP Wymott 5
Conduct of the Investigation 6
Key Findings 7
Recommendations 12
3
Summary
1. The man died in February 2005 whilst in custody at HMP Wymott. He
had been taken ill on B wing at approximately 12:00 noon, complaining
of breathlessness and feeling sick. He was taken to his cell where he
began to lose consciousness. Medical staff attended and attempted
unsuccessfully to resuscitate him. The man was pronounced dead at
1:33pm.
2. Following a post mortem, the Consultant Pathologist, concluded that
the man died of (a) Pulmonary Embolism (b) Deep vein thrombosis.
3. The clinical review carried out by Chorley and South Ribble Primary
Care Trust, examined the man’s medical records. The main concerns
identified were regarding the man’s mental health status and also that
he was on suicide watch on more than one occasion. The review also
notes: “it would appear that the man did not come forward to discuss
his problems as often as he might and that it was often following a
letter or phone call from his wife or mother that he was seen by health
care staff. However, a history of health problems has been noted.
These included diabetes (managed by diet alone, not obviously
monitored during his time in prison), depression, arthritis or
osteoporosis of the arms, and a possible previous diagnosis of bowel
cancer.”
4. The clinical review raises concerns about the medical care given to the
man whilst in custody.
4
HMP Wymott
5. Wymott prison is a Category C training prison, located near Leyland in
Lancashire. Half of the prison provides accommodation for vulnerable
prisoners. (Vulnerable prisoners are those who have requested to be
isolated from the normal accommodation areas of the prison, usually
for their own safety and protection.)
6. In December 2003, the prison was inspected by HM Chief Inspector of
Prisons. The inspection found that 81 per cent of the prisoners
surveyed felt safe, and that the relationships between prisoners and
staff were respectful. The Chief Inspector described the prison as a
good, well managed prison.
5
Conduct of the Investigation
7. On 24 February, my investigator met with the Acting Deputy Governor
at Wymott who briefed him of the circumstances surrounding the death
of the man. He provided the records relating to the man, escorted him
to the area where the man had been taken ill and to the cell where he
died. The initial findings of the investigation were fed back to the
Acting Deputy Governor at the end of the visit.
8. My investigators forwarded the man’s medical record to the Chorley
and South Ribble Primary Care Trust, in order that a clinical review
could be carried out. The PCT raised concerns about the healthcare
the man received during his stay in prison. These have been
discussed with the prison’s Healthcare Manager.
9. One of my Family Liaison Officers and the investigator met with the
man’s wife to talk about his care and treatment whilst he was in
custody. The man’s wife raised concerns about the medical care he
received whilst in prison and also about his location.
6
Key Findings
10. An examination of the wing Observation Book shows that, on 28
January 2005 at 11:00pm, the prison received a telephone call from the
man’s wife to say that he had told her that he would kill himself, as he
was “unable to go on any more”. A member of the wing staff saw the
man, and an F2052SH document was opened to monitor him.
F2052SH is a document used by the Prison Service and can be
opened by any member of staff who is concerned about a prisoner who
may be suicidal or intending to self-harm. It requires prison staff to
monitor and record their observations and conversations with the
prisoner. Once it has been opened, the prisoner is invited to meet with
a multi-agency prison team to discuss their concerns. An action plan is
developed, which is reviewed periodically. The man had not seen his
family for six months, and this was making him feel depressed. He
was advised to speak to his Personal Officer, or other wing staff, to
discuss a transfer nearer to his home. The investigation has not
established if the man did speak to anyone about this advice.
11. Three weeks later on 19 February, at approximately 12:10pm, another
prisoner approached two Officers to inform them that the man was
feeling unwell. One of these officers said that they responded
immediately to the information. The other of the two officers saw the
man leaning against a cupboard and noted that he was very pale. The
man complained of breathing difficulties and the officer requested
“Code Blue” assistance from the prison Healthcare Department, via the
prison radio system. Code Blue is the term used to describe a patient
with breathing difficulties. It is used by a number of prisons to alert
healthcare staff to the type of incident and the medical response
required. This is good practice.
It is good practice that the prison uses different emergency
codes, which enable staff to determine how to respond to an
alarm.
12. Three nurses responded to the call and found the man at the top of the
stairwell in B wing, complaining of breathlessness. Two of the nurses
assessed the man’s condition, and the third went to the medical
treatment room on B wing to collect oxygen.
13. One of the nurses who assessed the man, in his report, noted that he
was: “complaining of breathlessness and a degree of epigastric
discomfort. His Glasgow Coma Scale was 15. The man mentioned he
had a similar episode a week ago, but had not mentioned it to anybody.
Concurrently oxygen was administered at a rate of 15 litres per minute,
via facial mask. On examination by another nurse, the man’s blood
pressure was found to be 130/60, his temperature was 36.5 and his
capillary refill was within normal limits.”
7
14. As it was lunchtime, and the area was busy with prisoners, the nurses
decided to move the man in a wheelchair to his cell which was a short
distance away. When they arrived at the cell, the man moved himself
onto the bed and the nurses remained with him.
15. At 12:31pm, one of the nurses was unable to obtain an Electro Cardio
Graph (ECG) reading and so an ambulance was called. The man
complained of feeling faint, his skin became clammy and he was
unresponsive. Two of the nurses commenced Cardio Pulmonary
Resuscitation (CPR), although they did not move him off the bed as
there was not enough room in his cell to place him on the floor.
16. The prison healthcare department has “grab bags”, which contain the
necessary equipment to deal with specific incidents of either breathing
difficulties or blood spillage. Once they receive a call to attend a
patient, they take the appropriate bag with them. My investigator
asked if a defibrillator was inside the bag that was taken to the cell. He
was informed that it was not, as it was not part of the usual grab bag
equipment. One of the nurses said that the paramedic staff had
informed him that the defibrillator would not have made any difference
in the man’s case. Whilst, this may be the case, there was no way of
the medical staff knowing that, and valuable time could have been
wasted by having to return to the department to collect the equipment.
This should be reviewed.
The Governor in partnership with the PCT should ensure that the
grab bag contains the necessary equipment to allow healthcare
staff to administer emergency life saving aid.
The Governor in partnership with the PCT should ensure that a
defibrillator is taken to any Code Red or Code Blue incident.
17. At 12:57pm, the paramedics arrived, connected the man to a cardiac
monitor and incubated him. As they were unable to locate a vein, they
administered adrenaline via a tube. Throughout the paramedics’
intervention, one of the nurses continued with CPR.
18. At 1:33pm, the paramedics stopped any further attempt to resuscitate
the man and pronounced him dead. The prison doctor, arrived at the
cell at 1:40pm.
19. At 2:00pm, the police arrived and examined the area, leaving 45
minutes later when the cell was sealed pending the arrival of the
undertakers.
20. I seek to involve the family of the deceased in all my investigations,
including those where the death was from natural causes. I employ
designated staff within my office as Family Liaison Officers (FLOs).
The FLOs work closely with the family and the investigator, and will
8
21. On 31 March, a FLO and one of my investigators met with the man’s
wife. She raised a number of issues relating to his health and asked
why she had not immediately been informed of his death. The man’s
wife also expressed concern at the distance that he had been located
from their home. I believe that the clinical review will answer her
concerns regarding her husband’s health.
22. With regard to the man’s location, it is clear from correspondence
between the Prison Service, the man’s wife and a Member of
Parliament, that the man’s location was based entirely on the nature of
his offence. This limited the number of establishments available to
accommodate him.
23. The Prison Service’s Resettlement Policy asks prisons to consider the
location of prisoners in relation to their home circumstances and to
develop family contact. However, the overriding factor of the policy is
to address offending behaviour and to equip the prisoner with the
necessary skills to remain offence free on release. It is unfortunate
that the personal needs of the man’s wife were not taken into account
when allocating the man to Wymott, which was difficult for her to travel
to.
24. The prison records show that the man provided the names of his
parents as his next of kin, which explains why his wife was not the first
contact point in the event of an emergency.
25. The man’s wife was asked how the prison had dealt with her and the
man’s property. She confirmed that the prison Liaison Officer had
been in regular contact with her, and that the majority of her husband’s
property and private money had been returned quickly and efficiently.
However, she told the investigation team that a key ring, spectacles,
and bracelet were missing. The man’s wife believed that he might
have passed the bracelet to another prisoner, intending him to repair it.
The investigator has not been able to identify who the prisoner was.
The Governor was informed about the missing property. He has
written to the man’s wife to confirm that they were missing, but that he
would return them should they be found at a later stage. However, an
examination of the cell clearance certificate for 21 February shows that
the officers have recorded “glasses” as being removed from the cell.
The Governor should clarify the items removed from the cell and,
if necessary, compensate the man’s wife for the lost spectacles.
26. The man’s wife was pleased that the Governor agreed to photograph
her husband’s cell, as she was unable to visit the prison. She
confirmed that the prison had offered assistance with the funeral costs.
I welcome the Governor’s actions.
9
27. The clinical review raises one concern about the care of the man. The
report notes, “Although it is always easy with hindsight to see where
omissions have been made. It is of concern that the health care staff
should have tacitly accepted a diagnosis of osteoporosis as the cause
of leg pain in a 38 year old man. There is no record of his legs having
been examined and there is therefore no evidence that a deep vein
thrombosis was ever considered or ruled out. I note that in the list of
concerns raised by the man’s wife was a statement that both his
mother and wife had contacted the prison with concerns about leg pain
and swelling in his leg. This is not recorded in the notes but may be
recorded elsewhere. If this is true then the fact of swelling in his leg is
very suggestive that he did in fact have a deep vein thrombosis, which,
sadly, is a treatable condition if caught in time.” The clinical review
finding has been forwarded to the Governor for action.
The Governor and Healthcare Manager of HMP Wymott should
meet with senior Primary Care Trust representatives to discuss
the findings of the clinical review and agree on any actions that
are required. A follow up meeting should then be arranged in a
further six months to review progress.
28. Although I do not think it requires a formal recommendation on my part,
medical staff should additionally be reminded of the need fully and
accurately to record information in the medical notes.
29. The final paragraph of the clinical review questions whether there is a
record of the man’s family contacting the prison to discuss the pain and
swelling in his leg. His mother provided a number of documents which
show that medical concerns had been raised with the Governor of
Blakenhurst, which is where the man was located at the time. The
reply from the Governor said that “the concerns you express about the
man’s health have been passed to the Medical Officer who will look into
them”. There is no record of the man’s mother being written to again
by the Governor or Medical Officer of Blakenhurst to explain the man’s
condition or of any intervention taking place.
30. On 10 March, the man’s parents wrote to my FLO to inform her that,
following a telephone call from the man when he described his leg as
swollen and his foot blue, they telephoned Wymott prison about their
concerns. They understood that the man was seen the following
morning by a doctor, informed that the pain in his leg was due to his
bone disease and given painkillers and anti-inflammatory drugs.
31. The man’s parents end their letter by saying that they had concerns
about his medical care, and that he would still be alive had his medical
condition been investigated properly
32. It is clear that the man’s parents and his wife telephoned and wrote
more than once to the Governors of Blakenhurst and Wymott to
10
11
Recommendations
Operational
 The Governor, in partnership with the Primary Care Trust, should ensure
that the grab bag contains the necessary equipment to allow healthcare
staff to administer emergency life saving aid.
 The Governor, in partnership with the PCT, should ensure that a
defibrillator is taken to any Code Red or Code Blue incident.
 The Governor should clarify the items removed from the cell and if
necessary, compensate the man’s wife for the lost spectacles.
Healthcare
 The Governor and Healthcare Manager of HMP Wymott should meet with
senior Primary Care Trust representatives to discuss the findings of the
clinical review and agree on any actions that are required. A follow up
meeting should then be arranged in a further six months to review
progress.
Good Practice
 It is good practice that the prison uses different emergency codes, which
enable staff to determine how to respond to the alarm.
12